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SAN JOAaQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENNIROI`NI ENTAL HEALTH DIVISION _ <br /> UNDERGROUND STORAGE TANK DISPOSITION TRACKING RECORD <br /> SECTION 1.-Public Health Services Environmental Health Division Tank Tracking Sheet shall accompany each tank affixed with <br /> its site identification number. The Tank Tracking Sheet is to be returned to Public Health Services Environmental Health Division <br /> within 30 days of'acceptance of the tank by the disposal or recycling facility. The permit holder is responsible for ensuring that <br /> this form is completed and retumed. <br /> FACILITY NAME: 26a( E I C- _ <br /> FACILITY ADDRESS: -7-71 -7 54 <br /> TANK ID #39 - 807 TANK SI �f"F0 TANK CONTENTS: <br /> SECTION? -To be filled out by tank rem <br /> Tank Removal Contractor: <br /> Address: &,-'6 L-0Zk7 0-. Cityigmv _ape! --Zip:_ M9 <br /> Phone#: D Date Tank Removed: <br /> SECTION 3 -To be filled out by contractor "decontaminating tank": <br /> Tank Decontamination Contractor: <br /> Address: 'Z5715- PAfZ� Pj©l1c-�y;4Rp ciry: RoN +,'h ,� zip: ?4eo/ <br /> Phone#: <br /> Authorized representative of contractor certifying through signature below that the tank has been deconumin<aced in an approved <br /> manner as required by Cal EPA. <br /> Name: Title: Signature: Date <br /> s <br /> SECTION 4 - To be signed and dated by an authorized representative of the treatment, storage, or disposal facility <br /> accepting tank and/or piping'. <br /> Facility Name: ,- 1 <br /> Address: 71557 f4} OULF V/4-Rp City: Zip: 94,501 <br /> Phone,.#: ( 5-10 ) S — I'�)1 <br /> Date Tank Received. <br /> Name: Title: Sipature: Date <br /> EH 23 046 (Revised 08/13/99) Page 10 <br />